The last four decades have seen survival rates for most major cancers markedly improve even as incidence rates have climbed. Such progress is widely attributed to an increased focus on early detection and intervention, particularly with cancers deemed highly “curable” if detected early. Also, many more end-stage cancers today are being rendered manageable for years or even decades, where previous generations of patients with similar diagnoses were given significantly shorter prognoses. With this success comes a host of new needs, mainly in the form of capacity and quality. Timely, affordable, quality care is the great challenge ahead. If this challenge is to be adequately met, community cancer centers need to play a greater role than ever.

1. Improving
Capacity
& Quality
Can
Help“Future
Ready”
BY NORMA FERDINAND
ELIZABETH HORENKAMP, MD
RAJ MATTHEW
BALA VERMA
Your
Program
T
he last four decades have seen survival rates for most major cancers markedly improve
even as incidence rates have climbed. Such progress is widely attributed to an increased
focus on early detection and intervention, particularly with cancers deemed highly “cur-
able” if detected early. Also, many more end-stage cancers today are being rendered manageable
for years or even decades, where previous generations of patients with similar diagnoses were
given significantly shorter prognoses. With this success comes a host of new needs, mainly in the
form of capacity and quality. Timely, affordable, quality care is the great challenge ahead. If this
challenge is to be adequately met, community cancer centers need to play a greater role than ever.
42 OI | September–October 2013 | www.accc-cancer.org

2. www.accc-cancer.org | September–October 2013 | OI 43
Building Capacity
The principal future readiness challenge facing the oncology
community is how to ensure that community cancer centers
can handle patient capacity so that the right treatment reaches
the right patient at the right time. Community cancer centers
are (and will remain) main gateways for initial assessment and
care. But as more people seek proper screening and care earlier
in the cancer continuum, many of these cancer centers will need
to build capacity to provide timely diagnosis and treatment of a
greater volume of patients.
A patient’s treatment path is punctuated with waits. Wait to
learn “if” they have cancer. Wait to learn “what kind” of cancer
it is. Wait for a consultation on how to treat the disease. Wait
for second opinions. Wait to find out how long the patient will
have to wait before he or she can begin treatment. Community
cancer centers should look at these “waits” as true access op-
portunities to bring patients to their physician strategists and
nurse tacticians. Effective management of patient flow can pay
significant dividends. In time, this efficiency frees up additional
capacity to consistently provide the same level of high-quality
care to more patients without having to expand treatment
hours, staff, or facilities.
Here’s a brief look at how one community cancer center used
Lean Six Sigma principles to make process improvements and
“future ready” itself.
Improvements Needed
Being unable to provide timely care to cancer patients is dis-
concerting to any oncologist—particularly knowing a patient
may wait more than 14 days to get an appointment. The
provider team at Hematology Oncology Medical Specialists
(HOMS), the anchor practice at Lancaster General Health
(LGH), faced this reality in 2011 and knew that improve-
ments were needed immediately. HOMS is part of a collabor-
ative team that provides comprehensive care for patients with
many types of cancer, including chemotherapy, as well as con-
necting with surgeons and radiation oncologists to develop
an individualized plan of care for each patient. Complicating
the situation was LGH’s plan to expand services through the
development of a state-of-the-art cancer center for the local
community.
LGH leadership understood that improving efficiencies within
this medical oncology practice would need to occur prior to the
expansion of services in the new cancer center and before the prac-
tice’s planned electronic medical record (EMR) implementation.
Getting Started
In order to truly understand the issues and challenges that
impeded workflow, our first step was to take a hard look at
the current state of the oncology practice and its associated
chemotherapy infusion services. Our goal was two-fold: to
improve patient access and, ultimately, obtain a substantial
boost in capacity. To achieve these goals, a combined team of
LGH Health System and HOMS practice leadership under-
stood that process improvements, combined with next gen-
eration technology, were required.
LGH made the decision to partner with Genpact, a global
business process management company that had spun-off
from GE (General Electric) in 2007. With this partnership
came the decision to use education and mentoring to intro-
duce and promote widespread use of Lean Six Sigma im-
provement methodology.
The LGH Experience
With the understanding that quality cancer care requires a
capable multidisciplinary team (wherein each member of that
team is assigned the appropriate roles and responsibilities),
we took a hard look at our processes. One of the first efforts
was to evaluate how we educated patients about their chemo-
therapy regimen. We made the decision to reassign that task
to licensed physician assistants (PAs), which freed up block
time for our physicians and added potential capacity for 84
new patient appointments annually.
Next, a close look at our physicians’ administrative pro-
cesses revealed two improvement opportunities. The first in-
volved reducing the time physicians spent looking for forms
by using a Lean Six Sigma 5S tool (Figure 1, page 44). Five S
A patient’s treatment path is
punctuated with waits. Wait to learn
“if” they have cancer. Wait to learn
“what kind” of cancer it is. Wait for
a consultation on how to treat
the disease. Wait for second opinions.
Wait to find out how long before he
or she can begin treatment.

3. 44 OI | September–October 2013 | www.accc-cancer.org
is the methodology of organizing a workspace for efficiency
and effectiveness by reducing waste, a powerful tool that can
be used to improve physical spaces, as well as processes. The
goal was to eliminate all but essential paperwork, and then
ensure a standardized location for easy document retrieval.
The second involved recognition that 75 percent of the “re-
quired” documentation on forms need not be done by the
physicians themselves. A detailed analysis of this paperwork
process, followed by some simple procedural changes, imme-
diately reduced the number of forms processed by our physi-
cians from five each day to one per week.
Without an active commitment to evaluating each work pro-
cess, small problems are easy to miss—yet they can have a nega-
tive impact on quality of care and the cancer program’s bottom
line. Something as seemingly insignificant as when insurance
co-pays are collected on the day new patients arrive for their
initial consult can make a difference in how patients view their
experience. Through analysis of our processes, we discovered
that well-meaning clerical staff often skipped asking a visibly
distraught patient for the required co-pay in person. Instead our
clerical staff was using mail to solicit payment, thus delaying
collection for weeks. By simply moving the collection of co-
pays to when patients were registering but had yet to have any
weighty interactions with a physician, we were able to improve
collections by 60 percent. This change also removed “bottle-
necks” in the already burdensome check-out process by 13 per-
cent (see Figure 2, right).
Next we looked at freeing up capacity by reducing our
staff “travel” time. For example, when our laboratory relo-
cated supplies to the specimen-receiving station, it reduced
staff travel by 180 steps a day. In our chemotherapy infusion
center, we were seeing travel waste as a result of a floor plan
that did not allow busy nursing staff to see each patient as he
or she arrived. Our nurses walked, on average, about 1,200
steps per day; the unit facilitator was walking nearly 3,000
steps per day.
After process mapping to visualize barriers, we used sched-
uling software and 5S tools to make improvements. Our im-
provements resulted in:
• A 66 percent reduction of walking by our nursing staff
• 40 percent improved utilization of the documentation area
• A 30 percent reduction of non-value-added time spent
searching for charts and supplies.
We also identified significant opportunities for improve-
ment in areas of “rework.” As an example, consider the
infusion order, a critical component in oncology treatment
work streams. Not surprisingly, these orders are among the
most complicated medication order sets required for patient
therapy. In addition, transmission of these orders to the com-
pounding pharmacy introduces the potential for increasing
points of error. Integrating the need for customization of each
order based on individual laboratory values often creates a
confusing process for the patients too. One patient safety ini-
The dual quest for capacity and
quality begins and ends with the
rigorous pursuit of more efficient
and effective patient-centered care.
Figure 1. Lean 6 Sigma 5S Tool
STEP 1.
SORT
Remove from the workplace all items that are not needed for current operation. Sorting means leaving
only the bare necessities. “When in doubt, throw it out.”
STEP 2.
SET IN ORDER
Arrange needed items so that they are readily accessible and labeled so that anyone can find
them or put them away.
STEP 3.
SHINE
Sweep and clean the work area. The key purpose is to keep everything in top working order so that
when someone needs to use something, it is ready to be used.
STEP 4.
STANDARDIZE
Define the “normal” condition of the work area and how to correct “abnormal” conditions. The standard
should be easily understood and easy to communicate using visual tools where possible.
STEP 5.
SUSTAIN
Implement solutions to address the root causes of work area organization issues. All staff must
be properly trained and use visual management techniques.

4. www.accc-cancer.org | September–October 2013 | OI 45
tiative has been to build redundancy into the process; how-
ever, this redundancy can affect both physician efficiency and
pharmacy productivity. By standardizing the ideal variables
necessary to accurately complete the orders through use of
“critical-to-completeness” protocols that could be quickly
implemented and easily followed, we increased our chemo or-
der completeness from 13 percent to over 80 percent at first
pass, while the required touch points for each order—defined
as any time a pharmacist, administering nurse, or ordering
physician needed to interact with the chemo order itself, often
for the reason of seeking clarification—fell by 46 percent.
We also looked at our scheduling process. Although it
seems obvious that a busy practice with a long wait for pa-
tient appointments would have very few open slots, this was
not the case at our oncology practice. A patient’s diagnostic
and treatment course is at the mercy of many variables beyond
the patient’s control, often forcing last-minute cancellations.
At the start of the process our cancellation block refill rate
was only 5 percent. In other words, our staff was only able
to fill 5 percent of the cancellations. After conducting a Lean
Evaluation of our block refill process, we developed a multi-
pronged approach that included visual management (visual
cues instead of the written word to communicate information) to
track cancellations and the creation of a standard process using
existing technology to refill potential slots. Enhanced timely
communication to our physician providers was also critical.
Our efforts in this area improved the practice’s cancellation
block refill rate to 75 percent.
One of the most difficult process improvements involved
inpatient daily rounding. Each physician rounded to his or
her own attributed patients every day, which resulted in re-
duced availability for office patients. Developing and imple-
menting a clear, single, dedicated rounder structure solved our
logistical problem and resulted in consistent treatment for the
inpatient population, as well as improved access for new pa-
tients requiring oncologic treatment.
Going Forward
The dual quest for capacity and quality begins and ends with
the rigorous pursuit of more efficient and effective patient-
centered care. Cancer patients are fighting a near constant
battle with fear and treatment-induced fatigue. It is not
enough to simply treat their disease. How we treat the person
burdened with that disease matters just as much. This premise
is the basis of the patient-centered care treatment delivered
at the new Ann B. Barshinger Cancer Institute located on the
grounds of the Lancaster General Health Pavilion. Our aim
for the new Cancer Institute is to arrange our providers so
that debilitated patients are largely anchored in one place. Us-
ing this non-moving patient model, care providers go to the
patient, instead of the reverse.
The precepts of Lean Six Sigma process re-engineering
require a consistent drive to remove non-value-adding activ-
ity and evaluate workflows that directly or indirectly impact
quality of care and its financial and emotional cost to patients.
Transformation is a journey, not a destination, and ongoing
efficiency-improvement efforts will be key to meeting tomor-
row’s cancer care challenge today.
Norma Ferdinand is chief quality officer, Lancaster General
Hospital, Lancaster, Pa. Elizabeth Horenkamp, MD, is head
of oncology at LGH’s Ann B. Barshinger Cancer Institute.
Raj Matthew and Bala Verma are Lean Six Sigma Black Belts
at Genpact, New York, N.Y.
Figure 2. A Process to Improve Co-Pay Collection
1 Three-minute collection process is moved from checkout to check-in.
2
Shorter checkouts free up 13% more capacity for processing departing patients.
3
More (exhausted) patients are now able to go home sooner after care is complete.
4
Time-of-visit payments rise 60% with the switch to requesting co-pay at check-in.
5
Post-visit collections are avoided, sparing patients “surprise” when bills arrive weeks after treatment.